Abdominal emergencies in surgical oncology.

INTRODUCTION: In general, abdominal emergencies are urgent situations that require a prompt and correct diagnosis and treatment. They involve a broad spectrum of diagnoses and can occur in all age groups. The situation is often modified in oncologic patients according to the extent and level of progression of the primary oncological disease. METHODS: A retrospective study was conducted to analyze the group of adult patients with abdominal emergencies treated in Masaryk Memorial Cancer Institute between 2011-2017. RESULTS: In total, 601 patients underwent emergency surgery during the 7-year period. The causes included gastrointestinal obstruction (43%), intra-abdominal inflammatory complications (33%) and bleeding (17%). Acute appendicitis or cholecystitis was the cause in only less than 4% of all patients. CONCLUSION: The problems of acute abdominal emergencies in oncologic patients are substantially different from those in the general population, particularly in terms of the causes where gastrointestinal obstruction is the leading cause.

The timing of ERCP in acute biliary pancreatitis.

Despite several studies, the role and timing of endoscopic retrograde cholangiopancreatography (ERCP) in the case of acute biliary pancreatitis (ABP) remains a subject of discussion.There is a clear indication of early ERCP within 72 hours in patients with ABP andcholedochal obstruction, moreover the ERCP within 24 hours in cases of cholangitis. However, the role of ERCP in patients with ABP without symptoms of cholangitis or concrements obstructing the bile duct is controversial. If ABP is indicated for the ERCP, the earlier the ERCP is performed the less complications it is associated with. The decision to perform ERCP is often based on findings from a biochemical and transabdominal ultrasound examination. The results of these examinations may, but may not, confirm the presence of stones in the choledochus. An effective and safe method approaching the sensitivity of ERCP in the diagnosis of concrements in the choledochus is endoscopic ultrasonography (EUS) and magnetic resonance cho-langiopancreatography (MRCP). The cholecystectomy should be performed to prevent a recurrence of pancreatitis and biliary problems after the successfully treatment of ABP. Key words: acute biliary pancreatitis choledocholithiasis cholangitis endoscopic retrograde cholangiopancreatography.

[Juxtapapillary duodenal diverticulum causing pancreatobiliary problems - case report and literature review]. / Juxtapapilární divertikl duodena jako prícina pankreatobiliárních potízí - kazuistika a prehled literatury.

UNLABELLED: Juxtapapillary duodenal diverticula are reported as a potential cause of many pancreatobiliary diseases. However, data concerning this association is inconsistent and the role of the diverticulum is often underestimated or even denied in clinical practice. This case report and literature review is aimed at pointing out this problem.Obstruction of the diverticulum with a food bezoar can be considered as an important clinical clue of the etiological role of the diverticulum in pancreatobiliary disease development.Endoscopic sphincterotomy is considered to be the treatment of the first choice, with surgery (diverticulectomy and/or biliodigestive anastomosis) reserved for cases where the minimally invasive approach fails. KEY WORDS: juxtapapillary duodenal diverticulum obstructive jaundice acute pancreatitis endoscopic papilosphincterotomy biliodigestive anastomosis.

Differentiating autoimmune pancreatitis from pancreatic cancer.

Differential diagnosis between autoimmune pancreatitis (AIP) and pancreatic cancer can be very difficult. The main clinical symptoms in patients with autoimmune pancreatitis are jaundice, weight loss, abdominal pain and new onset of diabetes mellitus. Unfortunately, the same symptoms could be observed in patients with pancreatic carcinoma too. Imaging methods as computed tomography (CT) scan, magnetic resonance imaging (MRI) and endosonography (EUS); together with serological examination (IgG4 and Ca 19-9) play the important role in differentiation autoimmune pancreatitis from pancreatic cancer. Extrapancreatic findings are distinctive in patients with autoimmune pancreatitis. In some cases the pancreatic biopsy is indicated, mainly in patients with focal or multifocal form of autoimmune pancreatitis. Response to steroids (decreased pancreatic or extrapancreatic lesion or damage) is distinctive to AIP. In clinical practice, CT scan seems to be the most reasonable tool for examining the patients with obstructive jaundice with or without present pancreatic mass. Stratification the patients with possible AIP versus pancreatic cancer is important. In patients with AIP it may avoid pancreatic resection, as well as incorrect steroid treatment in patients with pancreatic carcinoma.

[Standardization of pancreatic cancer specimen pathological examination]. / Standardizace patologického vysetrení resekátu pankreatu.

INTRODUCTION: The frequency of R1 resections for pancreatic cancer in studies where a non-standardized protocol of pathological evaluation of the specimen is used varies from 17 to 30%. The aim of our study is to apply the standardized (so-called Leeds) protocol of resected pancreatic specimen pathological examination, and to evaluate the frequency of R1 resections for pancreatic cancer using this new protocol. MATERIAL AND METHODS: Ninety-one patients who underwent pancreatoduodenectomy for pancreatic cancer were included in the study. This group was divided into two subgroups: patients examined by the Leeds protocol (n=20) and those examined by a non-standardized pathological protocol (n=71). The R1 resection rate was evaluated separately in each group. The positivity rate of every individual resection margin was specified in the Leeds protocol group. The correlation of R1 resection rate and "tumour - resection margin distance" parameter was evaluated. The tumour infiltration of peripancreatic adipose tissue was assessed in the non-standardized group. RESULTS: In the Leeds protocol subgroup, R1 and R0 resection rate was 60% (12/20) and 40% (8/20), respectively. Resection line positivity rates were as follows: dorsal 45% (9/20), ventral 35% (7/20), VMS 20% (4/20), cervical 20% (4/20), AMS 15% (3/20). The correlation between the tumour - resection line distance and R1 resection frequency was the following: direct infiltration 30% R1, tumour-resection margin border 0.5 mm 50% R1, 1mm 60%, 1.5 mm 75% R1, 2 mm 80% R1, >2 mm 80% R1. If the criterion of resection line positivity ( 1mm) was set, the R1 resection rate difference between the two groups was of statistical significance. In the subgroup where the non-standardized protocol was used (n=71), R1 resection was recorded in 25 (35.2%) patients. The main cancer-positive areas were peripancreatic adipose tissue in 26.8% (19/71) of cases, and VMS, AMS or retroperitoneal line in 8.5% (6/71), respectively. R0 resection was achieved in 46 (64.8%) patients. The statistically significant (p=0.046) difference in R0 and R1 resection rates was detected (Leeds protocol and non-standardized one: R0 40.0% vs. 64.8% and R1 60.0% vs. 35.2%, respectively) in the studied groups. CONCLUSION: The rate of R1 resections for pancreatic cancer increased in all studies, including ours, where the standardized (Leeds) protocol of pancreatic specimen pathological examination was used. The higher R1 resection rate when using the Leeds protocol is approaching to the local recurrence rate of pancreatic cancer. Therefore, the Leeds protocol can provide more realistic evaluation of local radicality of pancreatoduodenectomy and can also offer more accurate evaluation of the surgical and adjuvant therapy of pancreatic cancer.

[Specificities of the diagnostics and therapy of exocrine pancreatic insufficiency]. / Zvlástnosti diagnostiky a terapie exokrinní pankreatické nedostatecnosti

Exocrine pancreatic insufficiency develops steadily; however, the initial reduction in secretion is practically not diagnosable. More advanced stages, which usually replicate morphological changes, can be determined with tests which asses the exocrine pancreatic capacity. Substantial damage of the pancreas and replacement of viable parenchyma with connective tissue is accompanied by the occurrence of steatorrhoea. This corresponds to a reduction in exocrine pancreatic secretion below 10% of physiological secretion. Exocrine pancreatic secretion tests are still not sufficiently sensitive for diagnosing early stages of pancreas defects and thus are not suitable for diagnostics. Furthermore, detecting reduced exocrine secretion does not provide any information about the aetiology of the disease, e.g. inflammation/tumor. The most precise test is a costly examination, including a stimulation of the gland with enterohormones; however, breath tests are usually recommended for the assessment of exocrine insufficiency therapy. Exocrine pancreatic insufficiency therapy consists of administering drugs containing pancreatin (amylase, lipase, and peptidase) to patients diagnosed with steatorrhoea, manifest pancreatic insufficiency. As standard, capsules containing microparticles of 1-2mm are recommended. They have a protective coating that prevents inactivation in the microparticles of the contained enzymes by gastric hydrochloric acid. The drug should be administered during each meal, i.e. several times a day. The most common mistake during pancreatic enzyme therapy is under dosage. The following rule applies to patients with digestive insufficiency: 40,000-50,000 UNT of lipase are to be administered during "main meals" and 25,000 UNT of lipase during morning or afternoon snacks. The drug should be taken during the meal; insufficient treatment and dosage are associated with insufficient digestion and absorption ofa number of substances and also with pancreatic malabsorption.

[Precancerous conditions and risk factors for pancreatic and bile duct cancer]. / Prekancerózní stavy a rizikové faktory karcinomu pankreatu a zlucových cest.

Pancreatic cancer has one of the worst prognoses of any type of cancer. Early detection and surgery is the best chance for cure. However, symptoms are typically vague and occur when the cancer is unresectable. Early detection through screening is likely to be the best hope to improve survival. The relatively low incidence of pancreatic cancer and the insensitive screening techniques currently available render this approach expensive and inefficient in the general population. Early detection and screening for pancreatic cancer in the current state should be limited to highrisk patiens. But hereditary factors account about 10% of patients with pancreatic cancer (familial pancreatic cancer, hereditary pancreatitis, Peutz Jeghers syndrom etc.). Continued efforts are needed to discover effective test to identify patients with nonhereditary risk factors who will benefit from screening and also to develop less invasive and more costeffective screening modalities aimed at controlling pancreatic cancer. A combined ap-proach of serum markers, genetic markers and specific imaging studies may prove to be the future of pancreatic screening.

[Endoscopic retrograde cholangiography with a single-balloon enteroscope in patients with Roux-en-Y hepatico jejunal anastomosis]. / Endoskopická retrográdní cholangiografie pomocí jednobalónkového enteroskopu u pacientu s Roux-Y hepatikojejunoanastomózou.

AIMS OF THE STUDY: The aim of this retrospective study was to evaluate our experience with using a single-balloon enetroscope for diagnostic and therapeutic endoscopic retrograde cholangiography (ERC) in patients with Roux-en-Y hepatico jejunal anastomosis (HJA). Due to the considerably changed anatomic circumstances after the surgery, ERC is, in comparison to the standard endoscopic retrograde cholangiopancraeaticography (ERCP), significantly more difficult to perform. PATIENT SAMPLE AND METHODOLOGY: The sample was followed up from January 2009 to September 2011. The study retrospectively reviewed 14 patients with Roux-en-Y HJA with symptoms of biliary obstruction. A total of 21 ERCs were performed in these 14 Roux-en-Y HJA patients using the single-balloon videoenetroscope Olympus SIF Q 180. RESULTS: Diagnostic ERC cannulation was successful in 11 of the 14 patients (79% success rate for the diagnostic ERC). One of the 11 patients had a normal finding on the ERC. The remaining 10 patients had a pathological finding on ERC that, in one patient (cystic dilatation of bile duct), was subsequently managed surgically. Endoscopic treatment was initiated in the remaining 9 patients (HJA stenosis in 4, choledocholithiasis in 2 and concurrent HJA stenosis and choledocholithiasis in 3) immediately after the diagnostic ERC; the surgery was successful in 8 of the 9 patients (89% success rate for the therapeutic ERC). The performed endoscopic therapeutic procedures included: balloon dilatation of HJA stenosis 9 times (6 patients), choledocholithiasis extraction - 5 times (5 patients), biliary plastic stent placement - 5 times (3 patients), removal of biliary stents placed by us - 5 times (3 patients). We did not observe any complications in our sample of 14 patients. CONCLUSIONS: ERC using a single-balloon enteroscope in patients with Roux-Y HJA is significantly more difficult than the standard ERCP due to different post-surgical anatomy. In our sample of patients, we achieved 79% success rate for the diagnostic ERC and 89% success rate for the therapeutic ERC. Additional time should be allowed for the individual procedures. Furthermore, the presence of an anaesthesiologist during these operations (deep analgosedation) is essential. This is a technically very demanding technique that, however, is effective and safe and importantly extends the options available for the management of biliary pathologies in these patients.

[Chronic pancreatitis in 2011]. / Chronická pankreatitida v roce 2011.

The incidence of chronic pancreatitis grows slowly but steadily. At present, alcohol is the most frequent risk factor, although the new forms of so called non-alcoholic chronic pancreatitis, such as genetically induced pancreatitis and its autoimmune variety, are carefully watched. Alcohol consumption continues to be most closely associated with the disease, though it is no more than a risk factor and other aspects, e.g., genetic predisposition, are prerequisite to the disease development. Imaging methods play a fundamental role in diagnosing the disease; non-invasive magnetic resonance and CT, invasive but safe endosonography, and diagnostically rarely used ECRP that, because of its invasive nature, is currently predominantly used for therapeutic purposes. Genetic markers are also exploited, including CFTR mutation, SPINK 1 and PRRS 1 gene, immunoglobulin G4 in the autoimmune form of the disease as well as, alternatively, pancreatic biopsy. Disease symptoms, i.e., pancreatic malabsorption (enzymes with high lipase content) and pancreatic pain are treated conservatively, with paracetamol as the first line therapy for pain followed, if necessary, by so called synaptic analgesics. Alternatively, endoscopic techniques (drainage) or surgery (drainage and resection) are applied. Hereditary and non-hereditary chronic pancreatitis is among the risk factors for pancreatic cancer and thus patients with these diseases should be closely followed up.

[Autoimmune pancreatitis and IgG-positive sclerosing cholangitis]. / Autoimunitní pankreatitida a IgG pozitivní sklerotizující cholangitida.

Sclerosing cholangitis is a heterogenous disease. Sclerosing cholangitis with an unknown cause is abbreviated PSC. PSC affects extra- as well as intra-hepatic bile ducts and since this is a permanently progressing fibrous condition, it leads to liver cirrhosis. The disease is often associated with a development of cholangocarcinoma and idiopathic intestinal inflammation. Causal therapy does not exist; liver transplantation is indicated. IgG4 cholangitis differs from PSC in a number of features. This form is, unlike PSC, linked to autoimmune pancreatitis (AIP) as well as other IgG4 sclerosing diseases. Anatomically, distal region of ductus choledochus is most frequently involved. Icterus is, unlike in PSC, a frequent symptom of AIP. There also is a distinctive histological picture--significant lymphoplasmatic infiltration of the bile duct wall with abundance of IgG4 has been described, lymphoplasmatic infiltration with fibrosis in the periportal area and the presence of obliterating phlebitis is also typical. However, intact biliary epithelium is a typical feature. IgG4 can be diagnosed even without concurrent presence of AIP. IgG4 sclerosing cholangitis is a condition sensitive to steroid therapy. At present, there is no doubt that IgG4 sclerosing cholangitis is a completely different condition to primary sclerosing cholangitis. From the clinical perspective, these diseases should be differentiated in every clinician's mind as (a) AIP is treated with corticosteroids and not with an unnecessary surgery, (b) IgG4 sclerosing cholangitis is mostly successfully treated with corticosteroids and the disease is not, unlike PSC, a risk factor for the development of cholangiocarcinoma.

[Pancreatic cancer--association with diabetes mellitus and smoking]. / Pankreatický karcinom--vztah k diabetes mellitus a kourení.

INTRODUCTION: Pancreatic cancer is a disease with rather poor prognosis. This can be explained, among other reasons, by unusually aggressive course of the tumour growth and, in the majority of cases, late, and thus further treatment limiting, diagnosis. In addition, no effective screening programme for pancreatic cancer is available and thus identification of risk factors associated with the development of pancreatic cancer represents a possible approach to diagnosing early stages of the disease. Smoking represents a general and diabetes mellitus a specific risk factor for pancreatic cancer. The aim of our prospective study in pancreatic cancer patients was to identify patients with diabetes mellitus and divide these into smokers and non-smokers--in association with the diagnosis of pancreatic carcinoma. MATERIALS AND METHODS: We included 83 patients, 50 men and 33 women, with pancreatic cancer who were divided into 3 groups--non-smokers with diabetes mellitus, smokers and smokers with diabetes mellitus; the mean age was 64.2 years in male and 59.8 years in female patients. Pancreatic cancer was confirmed histomorphologically from pancreatic biopsies or a histology of pancreatic tissue obtained during a surgery. RESULTS: Pancreatic cancer was diagnosed after 3 or more years in patients with diabetes mellitus, the majority of diagnoses in smokers were made within the first year from the first dyspeptic symptoms. We found that the proportion of patients with subsequent diagnosis of pancreatic cancer increased with the number of cigarettes smoked per day (33.3% up to 10 cigarettes per day and 66.5% over 10 cigarettes per day). The highest incidence of pancreatic cancer, in 42 persons (50.6%), was associated with concurrent diabetes and smoking. CONCLUSION: Pancreatic cancer was identified in 24% of patients with diabetes mellitus, 25.3% of smokers with no diabetes and in more than 50% of smokers with diabetes mellitus. We assume that smoking is an independent risk factor for pancreatic cancer induction and it importantly increases the risk of pancreatic cancer in patients with diabetes mellitus.

Autoimmune pancreatitis--recent advances.

Autoimmune pancreatitis (AIP) is recognized as a distinct clinical entity, identified as a chronic inflammatory process of the pancreas in which the autoimmune mechanism is involved. Clinically and histologically, AIP has two subsets: type 1--lymphoplasmatic sclerosing pancreatitis with abundant infiltration of the pancreas and other affected organs with immunoglobulin G4-positive plasma cells, and type 2--duct centric fibrosis, characterized by granulocyte epithelial lesions in the pancreas without systemic involvement. In the diagnosis of AIP, two diagnostic criterions are used--the HISORt criteria and Asian Diagnostic Criteria. In the differential diagnosis, the pancreatic cancer must be excluded by endosonographically guided pancreatic biopsy. Typical signs of AIP are concomitant disorders in other organs (kidney, liver, biliary tract, salivary glands, colon, retroperitoneum, prostate). Novel clinicopathological entity was proposed as an 'IgG4-related sclerosing disease' (IgG4-RSC). Extensive IgG4-positive plasma cells and T lymphocyte infiltration is a common characteristics of this disease. Recently, IgG4-RSC syndrome was extended to a new entity, characterized by IgG4 hypergammaglobulinemia and IgG4-positive plasma cell infiltration, this being considered an expression of a lymphoproliferative disease, 'IgG4-positive multiorgan lymphoproliferative syndrome'. This syndrome includes Mikulicz's disease, mediastinal fibrosis, autoimmune hypophysitis, and inflammatory pseudotumor--lung, liver, breast. In the therapy of AIP, steroids constitute first-choice treatment. High response to the corticosteroid therapy is an important diagnostic criterion. In the literature, there are no case-control studies that determine if AIP predisposes to pancreatic cancer. Undoubtedly, AIP is currently a hot topic in pancreatology.

Combined treatment of achalasia - botulinum toxin injection followed by pneumatic dilatation: long-term results.

Injection of botulinum toxin (BT) and pneumatic dilatation are available methods in nonsurgical treatment of achalasia. Authors anticipate beneficial effect of prior BT injection on the success of pneumatic dilatation and duration of its effect. There are no long-term data available to assess efficacy of combined treatment. From 1998 to 2007, 51 consecutive patients (20 men and 31 women, age 24-83) with achalasia were included and prospectively followed up. Each patient received injection of 200 IU of BT into the lower esophageal sphincter (LES) during endoscopy and 8 days later pneumatic dilatation (PD) under X-ray control was performed. The follow-up was established every 3 months first year and then annually. The efficacy was evaluated by a questionnaire concerning patient's symptoms and manometry. Results were compared with 40 historical controls (16 men and 24 women, age 26-80) treated by PD alone using the same method and follow-up. Fifty-one patients underwent combined treatment. Four patients failed in follow-up and were not included for analysis. The mean duration of follow-up was 48 months with range 12-96 months. Thirty-four of forty-seven (72%) patients were satisfied with results with none or very rare and mild troubles at the time of the last visit. Forty-one patients were followed up more than 2 years. Effect of therapy lasted in 75% (31/41) of them. In 17 patients, more than 5 years after treatment, effect lasted in 12 (70%). Mean tonus of LES before therapy was 29 mm Hg (10-80), 3 months after therapy decreased to 14 mmHg (5-26). The cumulative 5 years remission rate (+/-95% CI) in combined treated patients 69% +/- 8% was higher than in controls 50% +/- 9%; however it, was not statistically significant (P= 0.07). In control group 1, case of perforation (2.5%) occurred. Eight patients (17%) with relapse of dysphagia were referred to laparoscopic Heller myotomy with no surgical complication. The main adverse effect was heartburn that appeared in 17 patients (36%). Initial injection of BT followed by PD seems to be effective for long-term results with fewer complications. But the combined therapy is not significantly superior to PD alone.

[Chronic pancreatitis and the skeleton]. / Chronická pankreatitida a skelet.

The aim of our work was to determine the incidence of bone demineralization in patients with chronic pancreatitis, following the relation between the funcionality of the pancreatic tissue and etiological factors in the development of osteopathy and calciophosphate metabolism. Prospectivelly, during 1 year we followed 55 patients with chronic pancreatitis of different etiology verified by endoultrasound. Patients with other possible cause of osteopathy were not included in the group. In the following of calciophosphate metabolism we determined different biochemical parameters and we measured the bone mass with densitometry in standard locations. In the patients that we followed we managed to show high proportion (43.7%) of bone demineralization, however, no relation between the bone demineralization and the grade of chronic pancreatitis or the operation of pancreas was proved. Vitamin D deficiency has a significantly negative impact on bone metabolism, which is potentiated by pancreatic insufficiency and long-time alcohol abuse.

[Our experience with endoscopic drainage of pancreatic pseudocysts]. / Nase zkusenosti s endoskopickou drenázní lécbou pankreatických pseudocyst.

INTRODUCTION: The authors first provide and overview of the main knowledge on pancreatic pseudocysts. They discuss the individual types of pancreatic pseudocysts, their clinical picture, complications and diagnosis. As part of the differential diagnosis, they emphasise the need to distinguish pancreatic pseudocysts from cystic tumours and benign cysts. Special attention is then paid to various modalities of treatment of pancreatic pseudocysts. METHODS: The authors present their own results of endoscopic drainage of pancreatic pseudocysts, one of the key options in the treatment of this condition. RESULTS: A total of 33 patients (24 men and 9 women) were treated by endoscopic drainage between September 2007 and March 2009. Endoscopic drainage was performed transduodenally in 4 patients and via the transgastric route in 29 patients; 6 times with endosonographic device and with duodenoscope after endosonographic alignment in 27 patients. CONCLUSION: The authors conclude that endoscopic drainage is an effective method of treatment of pancreatic pseudocysts.

[Incidence of pancreatic carcinoma in persons with chronic pancreatitis]. / Incidence pankreatického karcinomu u osob s chronickou pankreatitidou.

INTRODUCTION: Pancreatic carcinoma is one of the diseases which mostly fail to be diagnosed on a timely basis, and there is no way to effectively screen patients for pancreatic carcinoma either. An option for the diagnosis of the "early glandular carcinoma" therefore resides in identification and systematic screening of patients with risk of pancreatic carcinoma. METHOD: We monitored 223 patients with chronic pancreatitis on a systematic basis from 1992 to 2005. During this 14-year period, we monitored the number of cigarettes smoked per year in addition to standard parametres measured by biochemical methods, endosonography, CT and ERCP exams, and assigned the alcoholic form of chronic pancreatitis to patients consuming more than 80g of alcohol per day on a systematic basis for more than 5 years in the case of men, and 50 g of alcohol per day in the case of women, and classed the patients according the TIGARO classification. RESULTS: Alcoholic etiology was proven in 73.1% of the examined patients, chronic obstructive form of pancreatitis was diagnosed in 21.5% of patients, and only 5.4% of patients were classified into the idiopathic pancreatitis group. Pancreatic carcinoma in the region of chronic pancreatitis was found in 13 patients (5.8%); stomach carcinoma was diagnosed in 3 patients with chronic pancreatitis, and oesophageal carcinoma in 1 patient of the total of patients monitored. Malignant pancreatic disease was diagnosed primarily in patients with alcoholic pancreatitis (4.5%). During the period of 14 years, 11 patients died, 8 of the deaths being associated with pancreatic carcinoma. CONCLUSION: Both pancreatic and extrapancreatic carcinoma in gastrointestinal location is a serious complication of protracted chronic, non-hereditary pancreatitis. Systematic identification and treatment of patients with chronic pancreatitis is therefore necessary for timely diagnosis ofgastrointestinal and pancreatic malignancies.

IgG4 Sclerosing Cholangitis - an Inflammation Imitating Tumour of the Pancreas and Biliary Tract.

BACKGROUND: Immunoglobulin (Ig) G4 associated sclerosing cholangitis is a rare inflammatory disease of the biliary tract. Although it is a very progressive condition, it responds to steroid therapy. IgG4 associated sclerosing cholangitis can mimic pancreatic carcinoma, cholangiocarcinoma, and primary sclerosing cholangitis; therefore, it is very important to obtain a differential diagnosis. IgG4 sclerosing cholangitis is a biliary form of IgG4 related systemic disease, in which afflictions of more organs is afflictions of more organs are common, typically biliary form together with pancreatic one. Nonspecific symptoms are obstructive icterus, fatigue, and weight loss. Atypical imaging of the biliary tree and pancreas can be used to distinguish it from other diseases. Laboratory data show elevation of bilirubin, liver enzymes, IgG4 and total IgG concentrations. Sometimes IgE is also elevated with the eosinophilia, oncomarker CA 19-9 and autoimmune antibody is sometimes detected. CASE: This article presents a case of IgG4 sclerosing cholangitis and its related findings. The patient was intially referred for suspected pancreatic tumour, the presumed diagnosis was later changed to cholangiocarcinoma type 4 with concurrent autoimmune pancreatitis. Atypical imaging in cholangiography made us suspect IgG4 inflammation and the diagnostic process began. CONCLUSION: The diagnosis of this disease uses so called HISORt criteria. It is a very complex process in which the success of steroid therapy as a final step can be conclusive, as it was in our case. It is essential to exclude a malign neoplastic growth. The authors declare they have no potential confl icts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 5. 12. 2018 Accepted: 10. 1. 2019.

Autoimunne pancreatitis.

Since Sarles et al. in 1961 reported a particular type of pancreatitis with hypergammaglobulinemia, many investigators have suggested that an autoimmune mechanism may be involved in some patients with pancreatitis. Recently, the concept of autoimmune pancreatitis (AIP) has been proposed in which several unique clinical, biochemical and imaging signs have been shown. In the TIGARO risk factor classification system of chronic pancreatitis proposed in 2001, autoimmunity was categorized as one of six of the risk factors. AIP is a chronic fibroinflammatory condition primary affecting pancreas. It is an atypical form of chronic pancreatitis characterized by sonolucent swelling of the pancreas, diffuse irregular narrowing of the pancreatic duct, and high serum IgG4 concentrations. Co-occurrence of extrapancreatic involvement, such as sclerosing cholangitis, retroperitoneal fibrosis, or salivary gland swelling were found: Histopathologic examinations detected extrapancreatic lesions such as lymphoplasmacytic inflammation and fibrosis, similar to those present in the pancreatic tissue, suggesting a common pathogenesis. These findings suggest that the disease involves a general involvement of the digestive system, although the presence of such involvement has not been fully elucidated. Steroids are a main therapeutic option in AIP.

[Endoscopic changes in the stomach and duodenal mucosa caused by minidose acetylsalicylic acid therapy and their prevention]. / Endoskopické zmeny sliznice zaludku a dvanáctníku pri lécbe minidávkou acetylsalicylové kyseliny a jejich prevence.

Minidose acetylsalicylic acid (ASA) administration is a significant risk factor for changes in the stomach and duodenal mucosa also in persons whose anamnesis does not indicate any previous symptoms of stomach disease or any other risk factor. One month ASA minidose therapy provoked changes in the stomach and duodenal mucosa in 43.7% of persons receiving the therapy for cardiologic or neurologic indications. The changes primarily involved erosion and were mainly located on the stomach mucosa, without signs of active bleeding. If ASA minidose therapy was administered for 1 month together with the proton pump inhibitor omeprazole, the rate of incidence of changes detected in the mucosa was statistically significantly lower, i.e. only 27.6 %, again without signs of fresh bleeding. The presence of Heliobacter pylori probably does not play a critical role; Heliobacter pylori was only detected in 34.1% of patients with changes in the mucosa. The persons who need ASA minidose therapy and especially those with risk factors must be secured by drugs with protective effect on the stomach and duodenal mucosa during ASA therapy, specifically in the form of proton pump inhibitors. Considering the benefit and complications of low-dose ASA therapy, it should not be indicated to persons with a low risk of cardiovascular or cerebrovascular complications and should be reserved for the treatment of high risk patients.